anti-tf antibody (alt-836) to treat septic patients with acute lung injury or acute respiratory distress syndrome

Conditions: Sepsis; Acute Lung Injury; Acute Respiratory Distress Syndrome

Summary: this is a prospective, randomized (1:1), double-blind, multi-center, phase ii clinical study to test the safety and efficacy of a recombinant chimeric anti-tissue factor antibody (alt-836) versus placebo in patients with sepsis and acute lung injury/acute respiratory distress syndrome (ali/ards). this study was divided into two parts and the first part of the study has been completed. in the first part of the study, sixty patients were randomized at a 1:1 ratio to receive one dose of the study drug or placebo. in the second part of the study, ninety patients will be randomized at a 1:1 ratio to receive a multi-dose treatment regimen of single doses every 72 hours up to a maximum of 4 doses of the study drug or placebo, provided there are no safety concerns.

tissue factor (tf)-dependent procoagulant activity and associated inflammatory processes may play a role in the severity and progression of ali/ards. recent studies demonstrated that tf levels were elevated in plasma and pulmonary edema fluid of ards/ali patients compared to control patients with hydrostatic pulmonary edema. these higher plasma tf levels were correlated with increased mortality, fewer ventilation-free days, the presence of disseminated intravascular coagulation and the presence of sepsis in patients with ali/ards, suggesting that systemic activation of coagulation may be clinically important in ali/ards. moreover, the pulmonary tf levels in patients with ali/ards were found to range between 0.5 and 2 nm, approximately 100-fold higher than simultaneous plasma levels, suggesting an intra-alveolar source of tf. thus, anti-tf antibody blockage of tf activity may therefore provide an effective therapeutic mechanism for the treatment of inflammatory disorders such as ali and ards. this study will test the hypothesis that administration of anti-tf antibody (alt-836) to septic patients with ali/ards will improve the clinical outcome by shortening the duration of mechanical ventilation for these patients.

Eligibility criteria:
inclusion criteria: 1. suspected or proven infection 2. hypoxemia: pao2/fio2is ≤300 mm hg 3. bilateral infiltrates consistent with pulmonary edema 4. positive-pressure mechanical ventilation through an endotracheal tube 5. no clinical evidence of left atrial hypertension to explain bilateral infiltrates 6. presence of at least three of the four sirs criteria. if only two criteria are evidenced, one must be temperature or wbc criteria 2 and 3 must occur within a 24-hour interval. the 48-hour enrollment time window begins when criteria 2, 3, and 4 are met. exclusion criteria: 1. \<18 years 2. inability to obtain consent 3. patient, surrogate, or physician not committed to full support 4. moribund state in which death was perceived to be imminent 5. morbid obesity 6. malignancy or other irreversible disease or condition for which 6-month mortality is estimated to be \>50% 7. known hiv positive with known end stage processes 8. prior cardiac arrest requiring cpr without fully demonstrated neurological recovery; or new york heart association class iv 9. pregnant or nursing 10. ali/ards induced by mechanical or chemical injury directly to the lung (including burns, trauma, and near drowning) 11. \>48 hours since all inclusion criteria are met 12. neuromuscular disease that impairs ability to ventilate without assistance 13. severe chronic respiratory disease, severe pulmonary hypertension, or ventilator dependency 14. chest wall deformity resulting in severe exercise restriction, secondary polycythemia, or respirator dependent 15. history of organ transplant (including bone marrow) 16. severe chronic liver disease, as determined by a child-pugh score \>10 17. hemoglobin persistently \< 7.0 g/dl 18. platelet count \<50,000/mm3 19. prolonged inr \>3 20. bleeding disorders unless corrective surgery has been performed 21. active internal bleeding 22. major surgery within 24 hours before study drug infusion, or evidence of active bleeding postoperatively, or plan for any major surgery within 3 days after study drug infusion. 23. diffuse alveolar hemorrhage from vasculitis 24. known bleeding diathesis 25. presence of an epidural catheter or lumbar puncture within 48 hours before study drug infusion or anticipation of receiving an epidural catheter or a lumbar puncture within 48 hours after study drug infusion 26. stroke within 3 months of study entry 27. trauma with an increased risk of life-threatening bleeding 28. a history of severe head trauma that required hospitalization, or intracranial surgery within two months of study entry 29. any history of intracerebral arteriovenous malformation, cerebral aneurysm, or central nervous system mass lesion 30. uses of certain medications or treatment regimens such as chemotherapy, unfractionated heparin, low-molecular-weight heparin, warfarin, antithrombin iii, acetylsalicylic acid, glycoprotein iib/iiia antagonists, thrombolytic therapy, and activated protein c are restricted. 31. participation in another experimental medication study within 30 days of study entry.

Keywords: sepsis acute lung injury acute respiratory distress syndrome ali/ards lung disease